A 57-year-old man with a history of alcoholic chronic pancreatitis and diabetes presented to another hospital with hypoglycemia. Our department was consulted because computed tomography revealed left pleural effusion and a cystic lesion in the mediastinum adjacent to the body of the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) showed stenosis of the main pancreatic duct and leakage of the contrast material from the pancreatic body. Therefore, we inserted a 5-Fr endoscopic nasopancreatic drainage tube into the fistula through the pancreatic duct. Then, we placed a pancreatic duct stent to bridge the disruption after achieving reduction of the mediastinal pseudocyst. On day 17 of hospitalization, we replaced the 7-Fr stent with a 10-Fr stent because of persisting stenosis and disruption. After ERCP showed improvement, the stent was removed and the patient was discharged on day 45. In this case, endoscopic transpapillary drainage was useful for treating the mediastinal pancreatic pseudocyst.

A 50-year-old man consulted a local doctor because of epigastric pain and intermittent fever. Enhanced abdominal CT showed inflammatory changes of the pancreas, as well as portal vein obstruction. After hospitalization for conservative medical treatment, his symptoms improved. However, follow-up at the outpatient department showed an increase of chronic inflammatory parameters and CT revealed a new intraabdominal cystic lesion. Infection of the cyst was suspected. We performed percutaneous cyst puncture and drainage, but a new cyst and pancreatitis developed subsequently, and improvement was not achieved. The amylase level in the cyst fluid was high (69606 IU/l) . In addition, the portal system was visualized by cystography via the cyst drain tube, revealing a connection between the portal system and pancreatic duct. ERP was performed for evaluation of the pancreatic c duct, revealing that the pancreatic duct was obstructed in the head of the pancreas, but the guidewire could be inserted through the cyst intraportally beyond the duct and there was contrast enhancement of the portal vein. The portal vein contained organized thrombus. We placed a transpapillary drain tube in the cyst. Because a new cyst did not develop and there was no relapse of pancreatitis.

A 74-year-old man had experienced dyspnea. Contrast-enhanced CT confirmed bilateral pleural effusion, pericardial effusion, and accumulation of 31×19 mm of fluid under the diaphragm. Due to high amylase levels in the pleural effusion fluid, a pancreatic pleural effusion was suspected. On day 15, ERCP was performed, which showed a narrowed pancreatic duct in the pancreatic body, with leakage of the contrast agent from the pancreatic body. We diagnosed pancreatic fistula and performed 5Fr ENPD. On day 21, it was replaced with a 7-Fr pancreatic duct stent ; however, the pancreatic fistula and pleural effusion showed little improvement, with increased pericardial effusion. On day 42, the stent was replaced with a 10-Fr pancreatic duct stent, and somatostatin was concurrently administered. However, infection of a pseudocyst just below the diaphragm was suspected. On day 54, we performed percutaneous drainage on the pancreatic fistula under the diaphragm. Subsequently, the pseudocyst improved.

A 16-year-old man was admitted because of recurrent acute pancreatitis after eating fatty foods. He denied abuse of alcohol and other drugs. The levels of serum triglyceride and cholesterol were extremely low. Transabdominal ultrasonography showed no gallstones but signs of early chronic pancreatitis. Endoscopic retrograde pancreatography via the minor papilla revealed that the dorsal pancreatic duct communicated with the loop-shaped meandering dorsal pancreatic duct, which ruled out pancreas divisum. No mutation associated with hereditary pancreatitis was found in the PRSS1 and SPINK1 genes. MMPD has been reported as a relevant factor in the onset of idiopathic recurrent acute pancreatitis. In this case, MMPD might have been relevant to recurrent acute pancreatitis and development of early chronic pancreatitis.

A 30s-year-old man was admitted to our hospital with abdominal distension. The physical examination revealed jaundice with right hypochondralgia, and the laboratory data showed high levels of the hepatobiliary enzyme. CT finding showed the cystic dilatation of the common bile duct (CBD) and the gallbladder wall thickness. EUS finding showed sludges in the dilated CBD and a stone in the pancreatic duct. ERCP finding showed two defects in the main pancreatic duct (MPD) . He underwent endoscopic pancreatic sphincterotomy and endoscopic nasopancreatic drainage. Later, he received percutaneous transhepatic gallbladder drainage (PTGBD) to reduce the jaundice. Percutaneous transhepatic cholangiography and nasopancreatography findings showed the cystic dilatation of the CBD to connect to the MPD and two defects in the MPD. He was diagnosed as pancreaticobiliary maljunction with pancreatic stones, and received a successful endoscopic pancreatic stone removal.

A 40-year-old female complaining of epigastric pain, was diagnosed with acute pancreatitis and admitted at local hospital. After recovery she was referred to our hospital for further examinations of dilatated common bile duct (CBD) and SOL in the head of pancreas.
MRCP showed dilatated CBD and SOL with low signal intensity on T2-weighted image in the main pancreatic duct (MPD) . EUS revealed 13.3 × 8.3 mm-sized isoechoic SOL with distal acoustic shadowing in the MPD, considered as pancreatic stone. In ERCP, we diagnosed as pancreaticobiliary malformation and found impaction of stone in MPD. So we performed endoscopic sphincterotomy (EST) and placed endoscopic nasal biliary drainage (ENBD) tube and endoscopic pancreatic stent. Biliary juice sampling through ENBD tube contained very high level of pancreastic enzyme (amylase : 16,032 U/L, lipase : 107,964 U/L) . For replacing ENBD tube to internal biliary stent, second ERCP was performed. Then we recognized divided stones and succeeded to remove stones by balloon catheter. Stones were milky white and compatible with protein plug as suspected.

A 70-year-old man was referred to our hospital for examination of a pancreatic cyst with a solid component suspected as IPMN. EUS revealed a spherical cystic lesion with a low-echoic solid component. CT scan revealed a pancreatic cyst with contrast effect at the margin and a solid component. The images suggested solid tumors with cystic degeneration, such as PNET. Under the tentative diagnosis of PNET, pancreatoduodenectomy was performed. Histologically, the tumor was diagnosed as NET G1 (WHO classification 2010) . Although most PNET are recognized as solid tumors, it was reported that 17% of the PNET had cystic degeneration. When cystic lesions are found in the pancreas, cystic degeneration of solid tumors such as PNET as well as cystic tumors such as IPMN must be differentiated.

A 60-year-old woman was admitted to our hospital with abdominal and back pain. CT revealed a low density mass in the pancreas. According to image and EUS-FNA histological findings, we diagnosed her condition as pancreatic neuroendocrine cell carcinoma (NEC) . Subsequently, she underwent systemic chemotherapy (CDDP+CPT-11) . After 4 cycles, the lesion reduced in size remarkably and she underwent surgery. However, brain metastasis appeared after surgery and rapidly progressed leading to the patient’s death. Chemotherapy based on the treatment for small cell lung cancer is also recommended for pancreatic NEC. However, there is no recommended chemotherapy schedule and no consensus for the strategy for brain metastasis in pancreatic NEC. Evidence showing pancreatic NEC is necessary, including a schedule for chemotherapy and a strategy for brain metastasis.

A 69-year-old woman visited our hospital with a chief complaint of respiratory distress. She had a history of laparoscopic-assisted right hemicolectomy for ascending colon cancer and postoperative adjuvant chemotherapy. Thereafter, she developed metastatic lung cancer and local recurrence in the abdomen. After right pneumonectomy, bronchial stump recurrence was discovered. Computed tomography revealed compression of the trachea due to superior mediastinal lymphadenopathy and complete stenosis of the right main bronchus. The situation was considered as an oncological emergency associated with airway stenosis. Airway stenting resolved the symptoms. Radiotherapy was performed. However, superior vena cava syndrome occurred and palliative care was subsequently administered.
Even if patients respond to chemotherapy or radiotherapy, it takes time for airway patency to occur. In an oncological emergency, airway interventions are extremely useful for improving respiratory symptoms.

A previously healthy, 41 year-old woman was referred to our hospital for further evaluation for a retroperitoneal tumor which was incidentally detected on a CT scan performed at another hospital. The patient was underwent endoscopic ultrasound (EUS) , which revealed 29×24mm low ehogenisity mass, suggestive of arising from gastric wall. The tumor could not rule out gastrointestinal stromal tumor (GIST) , therefore EUS-FNA was attempted with 22 gauge needle via stomach with success. Histrogical specimen did not yield a conclusive diagnosis, therefore, surgical resection was performed. The final histopatological results of surgical specimen showed Castleman’s disease, a hyaline-vascular variant type.
Castleman’s disease of the retroperitoneum is a very rare disease, which has been described that it is difficult to diagnose preoperatively. And there is only a few reports of EUS-FNA for Castleman’s disease. We report a case of retroperitoneal Castleman’s disease which was difficult to diagnosis only by EUS-FNA. This report showed limitation of EUS-FNA for diagnosis for Castleman’s disease, but some possibility of it.